The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively.

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Question 1 of 5

The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively.

Correct Answer: B

Rationale: The client's inability to effectively clear the airway due to pain and sputum production hinders the cough mechanism, making 'Ineffective airway clearance' the most appropriate nursing diagnosis. Although impaired gas exchange may occur due to the pneumonia, the immediate issue is the inability to clear the airway. 'Ineffective breathing pattern' does not address the specific issue of airway clearance. 'Anxiety' is not the priority when the focus should be on the physical complications of pneumonia.

Question 2 of 5

Which of these statements by the nurse is incorrect to use to reinforce information about cancers to a group of young adults?

Correct Answer: A

Rationale: The corrected statement in choice A emphasizes limiting red meat for the prevention of stomach cancer, which is more accurate than avoiding all meats. By focusing on red meat specifically, it provides clearer guidance to young adults. Choice B is not the correct answer as it provides accurate information about prostate cancer being the most common cancer in American men and its impact on sexuality and life quality. Choice C is also a valid statement, correctly highlighting colorectal cancer as the second-leading cause of cancer-related deaths in the United States. Choice D provides accurate information about lung cancer being the leading cause of cancer deaths in the United States and emphasizes its preventability among cancers, making it a valid statement for reinforcing information about cancers to young adults.

Question 3 of 5

A client is admitted for COPD. Which finding would require the nurse's immediate attention?

Correct Answer: B

Rationale: Restlessness and confusion are signs of hypoxia and hypercapnia in a client with COPD, indicating that the client's condition may be deteriorating rapidly. Immediate attention is necessary to prevent further complications. Nausea and vomiting (Choice A) may be related to various factors but do not directly indicate respiratory distress. Low-grade fever and cough (Choice C) are common in COPD and may not require immediate intervention. Irritating cough and liquefied sputum (Choice D) are typical symptoms of COPD exacerbation but do not signal an immediate need for attention as restlessness and confusion.

Question 4 of 5

A client has been admitted for meningitis. In reviewing the laboratory analysis of cerebrospinal fluid (CSF), the nurse would expect to note

Correct Answer: A

Rationale: High protein levels in the cerebrospinal fluid are indicative of bacterial meningitis, as the presence of bacteria in the CSF leads to increased protein production. Elevated protein levels can be seen in inflammatory conditions like meningitis. Choice B, clear color, is not expected in meningitis as it is typically associated with cloudy or turbid CSF. Elevated sed rate (choice C) and increased glucose (choice D) are not typically associated with the laboratory findings seen in meningitis.

Question 5 of 5

A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea, and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to

Correct Answer: A

Rationale: The correct answer is to suggest 3 to 4 warm sitz baths per day. Warm sitz baths can soothe the irritated genital area, reduce pain, and promote healing of the lesions associated with genital herpes. Cleansing the genitalia with soap and water or spraying warm water over the genitalia after urination may further irritate the lesions. Applying heat or cold to lesions as desired may not provide the same level of comfort and healing as warm sitz baths.

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